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From the *Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; †Reproductive Health and HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa; and ‡Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

SOUTH AFRICA IS ONE OF THE COUNTRIES hardest hit by the HIV, and it is estimated that there are more people living with HIV/AIDS in South Africa than in any other country in the world.1 We have documented high levels of HIV infection in young people in South Africa: young South African women are infected at 2 to 3 times the rate of young men and by the time a woman reaches age 21, she has a 1 in 3 chance of being HIV infected.2 Despite declines observed in other countries in sub-Saharan Africa including Uganda and more recently in Kenya and Zimbabwe, South Africa has failed to see a significant decline in the HIV epidemic nationally. However, it should be noted that there are some indications from the 2006 Antenatal Clinic (ANC) survey that HIV prevalence is at least stabilizing and may be declining in young women aged 15 to 24 years.3

In this issue of STD, Katz and Low-Beer assess the sexual behaviors of young people from numerous sexual behavior surveys conducted in South Africa during the past 10 years, including our national youth survey.4 They compare these behaviors to those of young people in Uganda at similar stages of the epidemic in an attempt to explore the role of sexual behaviors in the South African youth epidemic. Surprisingly, the data reviewed show that young people in South Africa reported less sexual activity, fewer lifetime sex partners, and more condom use during the “stabilization” of the South African epidemic than did Ugandan youth during the decline of the Ugandan epidemic. Likewise, we have reported that young people in the United States (where <1 in 1000 youth are infected) report far more “high risk” sexual behaviors than their South African counterparts, when examining traditional measures of sexual behavior.5

The results described are entirely based on self-reported sexual behaviors, and are therefore dependent on memory, and likely reflect “social desirability” bias. However, surveys conducted with different youth samples and by different organizations have been consistent in the levels of behaviors found among South African youth.2,6,7

Although sexual exposure is an essential element for HIV transmission, the data suggest that the behaviors of South African youth are not sufficiently different than Ugandan youth (or youth in other parts of the world) to explain the magnitude of the epidemic in the South African population. This issue is truly critical because the results help to shape global HIV prevention strategies that have increasingly been subjected to critical review.8

If high-risk sexual behavior alone does not explain the South African HIV epidemic, then other social and biologic forces must play a critical role. First, the epidemiology of the epidemic deserves attention. Because 16% of all South Africans are HIV infected,9 the probability of coming into contact with an HIV-infected sexual partner is high. Sexual encounters traditionally deemed “low risk” lead to the possibility of HIV acquisition. Second, the traditional belief that HIV is difficult to acquire through heterosexual intercourse is simply not correct.10 The efficiency of HIV transmission is dramatically increased by cofactors that raise the genital tract viral burden such as early (acute) and late HIV disease and sexually transmitted infections (Powers K, Poole C, Pettifor A, et al, submitted for publication). The HIV types in Africa (and especially clade C) may be more contagious.11 South Africans may also be more susceptible to HIV because of genetic factors, a low innate barrier to HIV (perhaps related to vaginal flora), pregnancy, sexually transmitted infections, and lack of male circumcision.12 Consistent with this idea, we reported high probabilities of HIV acquisition among young women in South Africa; approaching close to 100% per partnership.13

These ideas affect prevention strategies. Greater emphasis must be placed on increasing awareness with regard to the high risk of HIV transmission and chance of having a partner who is HIV infected (1 in 3 in many sub-Saharan African countries). The majority of youth in South Africa—even those found to be HIV-positive—believe that they are at low risk for HIV acquisition.14 Prevention messages must emphasize the great risk(s) of concurrent sexual relationships, an intervention just as important as overall reduction in partner number.15,16 Programs should also consider providing information to young women on the increased risk of HIV infection posed by even slightly older male partners. Continuing to emphasize the role of significantly older “sugar daddies” in the spread of HIV confuses the greater risk of mixing with men who are only a few years older and yet have the highest prevalence of infection.17

There is a political dimension to HIV prevention in South Africa as well. It is widely believed that some of the success in Uganda in controlling HIV (regardless of the precise mechanism) can be ascribed to concomitant HIV prevention from all levels and sectors in the country. The South African government has failed to provide optimal leadership around HIV prevention and care,18–25 which might partially account for sustained differences in the epidemic(s) reported by Katz and Low-Beer.

The HIV pandemic will not simply go away,1 and no single prevention “magic bullet” (e.g., a vaccine) is on the horizon. The magnitude and scope of the problem do not allow us the luxury of simply observing the spread of the virus; we have no option but to work tirelessly to develop better HIV prevention strategies. But development of better strategies requires a complete and total knowledge of “the enemy.” Although it is perhaps easy to focus on sexual behavior(s), the actual data, nicely summarized by Katz and Low-Beer, lead to a far more complex and nuanced picture. Unraveling this puzzle is critical to successful HIV prevention.